Resection of the esophagus is most commonly performed for the treatment of esophageal carcinoma. Two histologic subtypes of this cancer exist, each with their own distinctive features. Worldwide, by far the most common type of esophageal cancer is squamous cell carcinoma (SCC). This tumor type is associated with smoking and alcohol intake, which are individual risk factors for SCC and also have a synergistic effect when combined. While rates of SCC in other countries remain high, over the past few decades the incidence in the USA has been steadily dropping—a change attributed to lower rates of tobacco and alcohol use.

At the same time, there has been a dramatic rise in the incidence of esophageal adenocarcinoma, such that adenocarcinoma has recently surpassed squamous cell carcinoma as the most common type of esophageal cancer in the USA. Esophageal adenocarcinoma is thought to occur as the end result of a sequence of events that culminate in carcinogenesis. The first step in this process is the development of gastroesophageal reflux disease (GERD), in which a lax lower esophageal sphincter allows acidic contents of the stomach to reflux into the lower esophagus. Chronic irritation from GERD can lead to transformation of the normal stratified squamous epithelium of the esophagus into a columnar epithelium, a change known as intestinal metaplasia—or Barrett’s esophagus. With continued insult, these columnar cells can become dysplastic, and may ultimately undergo malignant degeneration into adenocarcinoma. The rise in rates of adenocarcinoma in the USA can in part be explained by the prevalence of obesity and associated GERD.

Patients diagnosed with GERD should be treated with medications and anti-reflux surgery, as indicated, in order to reduce acid reflux and prevent subsequent intestinal metaplasia. Once a diagnosis of Barrett’s esophagus has been established, patients should be monitored closely with endoscopy and random esophageal biopsies. Most patients with mild dysplasia will never go on to develop esophageal cancer, however if high–grade dysplasia is present on biopsies, there is a significant chance of carcinoma being present elsewhere in unsampled areas of the esophagus. For this reason, the presence of high-grade dysplasia is in itself considered an indication for esophagectomy. However, newer approaches to the treatment of high-grade dysplasia and carcinoma in situ are emerging, including photodynamic therapy, endoscopic mucosal resection, and thermal ablation of affected areas. These approaches offer less invasive alternatives to esophagectomy and appear to have favorable results in appropriately selected patients.

Unfortunately, most patients with esophageal cancer present with advanced disease. Typical symptoms at presentation are progressive dysphagia and unintentional weight loss. Any patient presenting with these complaints should undergo upper endoscopy for evaluation. If esophageal cancer is discovered, an endoscopic ultrasound is performed to assess the tumor depth (T stage) and to look for suspicious appearing lymph nodes (N stage). A CT scan is obtained to visualize the tumor’s relationship to adjacent structures and to assess for distant metastatic disease (Fig. 5.1). PET is very useful in evaluating for metastatic disease, since esophageal cancer tends to be highly metabolic and thus glucose-avid (Fig. 5.2).

The minority of individuals who present with early stage disease may proceed directly to surgical resection. However, the majority of patients will have locally advanced disease and are typically treated with neoadjuvant chemoradiation therapy prior to surgery.

Presurgical nutritional optimization is an important component of the treatment of a patient with esophageal carcinoma. Endoscopic stent placement can be a useful method of relieving the dysphagia that patients have due to the mass effect of the tumor (Fig. 5.3). This minimally invasive procedure allows patients to resume oral intake and maximize their nutritional status. If stent placement is not feasible, a jejunostomy tube can be used for enteral feeding during treatment. Gastrostomy tubes should be generally avoided since the stomach may be used as the future reconstructive conduit. Placement of a jejunostomy tube is described in detail in the section on enteral access.

Squamous cell carcinoma of the esophagus is significantly more chemoresponsive than adenocarcinoma, and some patients undergoing neoadjuvant therapy will achieve complete remission of their tumor. It is now increasingly accepted that these complete responders do not require esophagectomy. Such patients are closely observed for signs of recurrence, at which point surgery can be reconsidered. Unlike squamous cell carcinoma, patients with adenocarcinoma rarely achieve complete response to neoadjuvant therapy, and surgical resection is nearly always required.

Although less common, esophageal surgery is also occasionally indicated for nonmalignant etiologies. Ingestion of bleach, lye, or other caustic agents causes chemical burns to the esophagus, resulting in stricture formation. Esophageal resection and reconstruction may be indicated for severe cases.